Postmenopausal and Irregular Vaginal Bleeding
In the majority of cases of irregular vaginal bleeding the examination findings are not worrying, and any abnormalities detected can be easily treated. In a small minority of women abnormal bleeding may be due to underlying changes within the lining of the uterus (womb) which may be more worrying such as endometrial hyperplasia (pre-cancerous changes) and cancer. In view of this it is important to carry out the appropriate investigations. A pelvic ultrasound scan is helpful in detecting abnormalities of the uterus and ovaries.
Abnormal vaginal and postmenopausal bleeding
Abnormal or irregular vaginal bleeding can occur before or after the menopause. Normal length of menstrual cycles is between 21 and 35 days. Cycles which are shorter that 21 days are always classified as being abnormal. Cycles which last longer than 35 days are likely to be abnormal, but some women have cycles longer than five weeks which are ovulatory (normal). Any bleeding which occurs between the periods is also considered abnormal.
Menopause is defined as the cessation of menstrual periods for longer than one year after the age of 45. The average age of the menopause is 51 years in the United Kingdom. Any vaginal bleeding which occurs after menopause in women who are not taking hormone replacement therapy is abnormal and it needs to be investigated. The same applies to women who are taking the continuous combined (‘non-bleed HRT’).
In the majority of cases of abnormal bleeding the examination findings are not worrying, and many abnormalities which are detected can be easily treated. In a small minority of women abnormal bleeding may be due to underlying changes within the lining of the uterus (womb) which may be more significant such as endometrial hyperplasia (pre-cancerous changes) and cancer. In view of this it is important to carry out the appropriate investigations. A pelvic ultrasound scan is helpful in detecting abnormalities of the uterus and ovaries.
Abnormal bleeding before menopause
Common causes of irregular bleeding include endometrial polyps and thickening of the lining of the uterus (endometrial hyperplasia). An ultrasound scan is helpful in these cases as it allows us to examine the uterus and endometrium in detail. Polyps and abnormal thickening of the endometrium can be detected on scan. Polyps can be easily treated by having a small procedure using a camera to examine the cavity of the uterus and remove the polyps. This can be performed as an out-patient or under general anaesthesia and your doctor will discuss this further with you. If abnormal thickening of the endometrium is detected on scan it may be necessary to perform an endometrial biopsy. This is a procedure whereby a sample of tissue is taken from the endometrium using a small plastic catheter. The doctor will discuss this with you in more detail at the time of the clinic visit.
A hormone imbalance can also contribute to irregular bleeding. On occasions this may lead to cysts forming within the ovaries. The ovaries are routinely examined during the scan and cysts can be diagnosed by the doctor performing the scan. These functional ovarian cysts tend to resolve spontaneously. As part of our routine practice all ultrasound findings are shared with the patient at the time of the clinic visit unless otherwise requested.
Vaginal bleeding after the menopause is not normal and should be investigated promptly. In the majority of cases the bleeding is due to a benign condition and women can be reassured following the examination. However, in a small proportion of women the bleeding may be due to pre-cancerous or cancerous changes within the endometrial lining.
The most common cause of bleeding is atrophic changes within the vagina. This can occur due to lack of hormones following the menopause, leading to the vaginal tissues being more fragile and bleeding easily. Other causes include endometrial polyps, and these can be diagnosed on ultrasound scan. If an endometrial cancer is suspected on the ultrasound examination or pre-cancerous changes (endometrial hyperplasia) the doctor may discuss the option of taking an endometrial biopsy to confirm the diagnosis. All women diagnosed with cancer in our clinic are referred to a cancer specialist for further care.
During the ultrasound examination the urinary bladder is routinely assessed and very occasionally bladder abnormalities can be diagnosed which can cause bleeding.